Hello and good evening and welcome to the American Psychiatric Association's Mental Health Equity Webinar Series. My name is Dr. Regina James and I am the Chief for the Division of Diversity and Health Equity and one of the Deputy Medical Directors here at the American Psychiatric Association. So again, welcome to our Looking Beyond Webinar Series. So this series was actually developed with the goal of bringing to the discussion table diverse disciplines and these disciplines could come together and move beyond sort of the conventional approach to a more interdisciplinary perspective of how we might address mental health and mental health care inequities. And this year, APA has developed a four-part series and assembled a wonderful panel of substance use and addiction experts to really address these questions around substance use and addiction in marginalized and minoritized communities. So our first webinar actually focused on vaping among minoritized youth. So if you did not have an opportunity to attend that live session, you can see an online recording and it's available at psychiatry.org. But tonight is the second part of our series and our esteemed panel will discuss how to address barriers and challenges in implementing evidence-based prevention and treatments, such as naloxone distribution and recovery support services in community settings. And they're going to cover a number of other areas as well, but I'm going to leave that to our moderator. So before we get started, I'd like to introduce our distinguished moderator, Dr. Andy Tompkins. Dr. Tompkins is the Director of the Division of Substance Abuse and Addiction Medicine at Zuckerberg San Francisco General Hospital and Professor of General Psychiatry and Behavioral Science at UCSF School of Medicine. Now, as a physician scientist, Dr. Tompkins' research is focused on novel medication development for the treatment of substance use disorders and the treatment of pain in persons managed on chronic opioids. He has authored over 47 peer-reviewed manuscripts, two book chapters, and presented both nationally and internationally. And he is a distinguished fellow of the American Psychiatric Association. So I'd like to introduce you to Dr. Tompkins. Thank you, Dr. James, and welcome, everyone. I'm sitting here in San Francisco, and my role as the moderator will be first to introduce our wonderful panelists, and then after that, provide a brief introduction on the topic, and then hopefully ask questions that will provoke an interesting conversation, debate, and then also take questions from the audience. We're here to learn together, and so let's get started. So going in, I believe, alphabetical order, I'm going to first introduce Dr. Dennis Antwon, who actually was a resident with me. We won't tell you how long ago that was, but we do both have gray hair. So Dr. Antwon is the director of both. He's at Johns Hopkins University School of Medicine and is the director of both the Cornerstone Clinic and Helping Up Mission in Baltimore and the Addiction Treatment Services Clinics at Johns Hopkins Bayview Medical Center, which include a licensed opioid treatment program and the Center for Addiction and Pregnancy. Dr. Antwon is board-certified in psychiatry and addiction medicine. He obtained his medical degree from Howard University, completed his psychiatric residency at the Johns Hopkins Hospital, and went on to complete an NIH-sponsored addiction research fellowship at the Behavioral Pharmacology Research Unit. The addiction treatment programs which he directs help underserved populations with substance use disorders and co-occurring mental health conditions. Dr. Antwon is a core faculty member of the Behavioral Pharmacology Research Unit, where he serves as a medical monitor and co-investigator of several NIH-funded clinical trials for advancing substance use disorder treatment. Beyond clinical care and research, he's a core faculty member of the Johns Hopkins Center for Health Equity and co-director of the Johns Hopkins Congregational Depression Awareness Program, which aims to address health disparities in otherwise overlooked communities. Dr. Antwon has been awarded many awards, including the Francis J. Lentz Award by the National Alliance for Mental Illness Metropolitan Baltimore Chapter. He received the Extra Mile Recognition from the United States Interagency Council on Homelessness in the category of mental health and trauma-informed care, and is a recipient of Johns Hopkins Medicine's 2022 Levi Watkins, Jr. Ideal Award. So thank you, Dr. Antwon. We'll look forward to hearing more from you in a little bit. Our second panelist is Dr. Oluwole Jagadeh. He is an assistant professor of psychiatry at the Yale University School of Medicine and an addiction psychiatrist at the Connecticut Mental Health Center. Dr. Jagadeh completed his medical education at the University of Ibadan in Nigeria, his general psychiatry residency at One Brooklyn Health Interfaith Psychiatric Residency Program, and his addiction psychiatry fellowship at Yale University School of Medicine. Additionally, he received a master's in public health at the George Washington University. He was a SAMHSA REACH scholar and recipient of the American Academy of Addiction Psychiatry Tribal Award, among others. And by the way, I think AAAP is having their conference right now. His core research interests include understanding inequities in addiction and addiction treatments among historically minoritized patients with substance use disorders, especially as it relates to the impact of structural racism and other social determinants of substance use disorders. Other areas of his focus include addiction education, addiction pharmacology, and co-occurring disorders. Dr. Jagadeh has contributed to several peer-reviewed publications and book chapters in the field of addictions and widely cited for his wonderful research work. Thank you, and we'll look forward to hearing from you in a little bit. And finally, Dr. Myra Mathis, she is the program director of the addiction psychiatry fellowship and is an assistant professor of psychiatry at the University of Rochester Medical Center. Dr. Mathis received her MD from the University of Rochester, completed her residency in general psychiatry and her addiction psychiatry fellowship also at Yale New Haven Hospital. She's currently a board certified in general adult and addiction psychiatry. Dr. Mathis is the medical director for Strong Recovery, University of Rochester Medicine's outpatient co-occurring disorders clinic, which houses an opioid treatment program and provides a full range of addiction and psychiatric services. She has been the contributing author to several peer-reviewed articles and book chapters, and her interests include racial health equity and social justice and psychiatry and addiction. She also loves medical education for students, residents, and fellows in the treatment of substance use disorders. So welcome Dr. Mathis, and we look forward to hearing from you in a little bit. So now for a brief introduction to this topic area. One I've spent my entire career at this point studying and seeing and watching. So the opioid crisis is a multifaceted epidemic that has gripped our nation and has not spared any demographic. However, when we delve into the unique experiences of African Americans, a narrative of compounded hardship emerges, highlighting disparities that demand our immediate attention and collective action. The Center for Disease Control and Prevention found in 2020 overdose death rates, which were the number of drug overdose deaths per 100,000 people, increased 44% for African Americans and 39% for American Indian and Alaska Native people compared to 2019. Specifically in 2020, the overdose death rate among Black males 65 years and older was nearly seven times that of similar age White males. And not only older individuals, but Black young people aged 15 to 24 experienced the largest rate of overdose death increase compared with changes seen in other age and race groups during 2019 to 2020. Unfortunately, these disparities continue during the COVID-19 public health emergency, and recent statistical modeling predicts Black men in their 30s and 40s will continue to have high overdose death rates until at least 2025, unless we act now. In my hometown of San Francisco, the overdose death rate in the non-Hispanic Black or African American community was always high. However, since the advent of fentanyl in the drug market here in 2019, Black individuals have six times the higher death rate compared to that of Whites, despite Blacks making up only 5% of the city's population. To understand the presence of these numbers, we must first acknowledge the historical roots that have shaped the landscape of healthcare inequities in African American communities. Centuries of systemic racism, socioeconomic disparities, and limited access to quality healthcare have contributed to a cycle of disadvantage that persists to this day. The opioid crisis, often viewed through a very narrow lens, unveils a broader tapestry of interconnected social and economic factors that disproportionately affect the African American population. When faced with the impact of substance use and addiction, African Americans encounter formal barriers on their path to recovery. Disparities to access to mental health resources, culturally competent care, and evidence-based treatments create a chasm between those seeking help and the assistance they desperately need. The stigma surrounding addiction, coupled with limited educational resources on mental health within these communities, exacerbates the challenge of seeking timely and effective care. The economic fallout from the opioid crisis further exacerbates existing inequalities. African Americans are more likely to face financial hardship due to addiction, limiting their ability to access comprehensive mental health services. The economic strain perpetuates a cycle of disadvantage, hindering not only recovery, but also preventing individuals from breaking free from the grip of addiction. The opioid crisis, of course, for those that have been in the treatment and research and education community, is not just an individual struggle, but a collective burden borne by entire communities. As we dissect the layers of this crisis, we must acknowledge the ripple effects that extend far beyond individual experience, and recognize the urgent need for a holistic, community-based approach to mental health care. In our panel discussion tonight, we'll explore the nuances of the opioid crisis among African Americans, shedding light on the intersectionality of race, socioeconomics, and mental health. Our journey today, and hopefully it will be a fun and productive journey, is a call to action, a plea for inclusivity, and a commitment to dismantling the barriers that perpetuate inequities in mental health care. Together, let us strive for a future where access to quality mental health services know no racial or economic boundaries. And as a reminder, you, the audience, are our vital participant in tonight's panel, and so please, there are two ways to put questions for us, panelists, using the Q&A function as well as the chat function, and we'll make sure to have at least 15 minutes at the end for us to see and to hear from you as well. So let's begin, and tonight is really meant to be a conversation, and so I will first ask a question to a specific panelist, and if a panelist wants to then answer in addition to that, we'll have each one after that. And I will be in the background making sure everyone gets their voices heard, and of course to monitor the chat and make sure the audience questions are answered. So Dr. Mathis, I'm going to start with you, and it's a good one. How does the historical context of systemic racism influence the disproportionate impact of the opioid epidemic on the African-American community, and what policy changes are needed to address these disparities? So thank you, Dr. Tompkins, for the question and for the introduction and context that you provided. So in your introduction, we heard a lot about systemic racism and its impact on health disparities in general, and certainly given the challenges of COVID-19 and the racial unrest and reckoning that happened in this country in 2020, we all became more aware of the impact of systemic racism on health disparities and health outcomes in minoritized communities, and in particular in the Black and African-American community. And that certainly sets the stage for how another health issue, the opioid epidemic, then impacts Black communities, right? So the issues of systemic racism that relate to redlining, which then leads to decreased resources and concentration of poverty for minoritized communities, that also impacts education, that impacts economic development and growth and attainment, all of those things set the stage for the health disparities that exist in Black and African-American communities. And then you add the additional policies that were leveraged towards Black and African-American communities as it relates to addiction, and that creates a unique lens for the impact of systemic racism on issues of substance use disorders, and in particular the opioid epidemic. So if we go back in time and we think about the 1970s, this isn't the first time that this nation has experienced an opioid epidemic or crisis. But in the 60s and 70s, the crisis was more concentrated in areas of poverty and concentrated in Black and African-American communities in particular. And when there was a public health issue related to addiction at that time that was concentrated in communities of color, the public response to that crisis was one that really prioritized law enforcement to a great degree, criminalization, right, that drug policy at that time really was a part of what fueled mass incarceration that also then further stripped communities of color of important resources that separated families, that limited individuals' ability to, let's say, reengage in society and have gainful employment that could then uplift their families. So it perpetuated those systems of poverty that were already existing due to policies that came before. And so when we think about the context of substance use disorders, opioid use in particular in Black communities and systemic racism, we have to appreciate that the factors of systemic racism that exist overall for Black communities are then compounded by the racialized way that substance use and opioid use in particular was perceived at that time and how it shifted as individuals started to think about opioid use in the early 2000s as no longer an issue that was only impacting communities of color, right, that there was a shift in mindset about how we should approach substance use, that there has been a reticence to employ law enforcement only tactics in this current era of the opioid epidemic. And that historical legacy in Black communities has absolutely not only impacted economic containment but also impacted the ways in which Black communities engage with health care system, engage with substance use disorder treatment. And so we really do need to be mindful of that historical context. And in terms of how we move forward, right, that we do need to be mindful of a racial justice lens in the implementation of new policies as it relates to things like opioid settlement fund use, for example. That we're very mindful of the need for racial justice policies that prioritize engagement of treatment for individuals from Black and brown communities. That we consider how we are engaging folks in our clinics, that our, as we're having this conversation today, that our use of culturally responsive techniques is really at the forefront of our clinical engagement. Because for Black communities, systemic racism and stigmatization are like two sides of the same coin. So thank you, Dr. Mathis. And I was wondering, Dr. Antwine, with your work with pregnant women specifically, can you talk a little bit about what it's like to be African American pregnant and with an opioid use disorder in Baltimore, where you are? Yeah, you know, I can certainly give the experience from what I've seen of the services. And it's almost like, as Dr. Mathis really brought up, there was this base layer of difficulties. And I think within the pregnant population, you see a, and you saw always a discrepancy between Black African American women and individuals that are of other ethnicities to show that there were higher mortality, morbidity rates, and infant mortality rates that well preceded this opioid epidemic. And then bring that into the standpoint of now we have this opioid epidemic that could make this worse. And there are a lot of ways that could be problematic. And I think that's done just from the base layer that there are difficulties with maternal mortality, infant mortality, and perinatal outcomes just from the beginning. But then you have the opportunity, unfortunately, that after a person delivers, that is a prime time for relapse. Within the first, really, one month, do you see a high rate of opportunity for relapse and overdose? And you put that in the context of an opioid epidemic where these more potent medications and substances are available, it really does highlight the difficulties that can arise for pregnant women and their babies, because that begins a cycle there of where does CPS come into the play? And is there removal and the beginning of a cycle of disconnection from this, hopefully, a good diet that can become really problematic when there's separation and ongoing overdose potential. So that is the beginning of the issue because you then need to think about what is the social context around this diet? Is there available treatment? Is there available social support? And are those persons affected, as Dr. Mathis mentioned, by all the other structural issues that have maybe pulled them away, whether it is incarceration, whether it is something that might have had to do with COVID itself, which was layered on top of the opioid epidemic and made things worse for medical outcomes. So putting things just on the pregnant person and the baby shouldn't be where it is. But unfortunately, due to all the layers that Dr. Mathis has pointed out and what happened during the opioid epidemic and COVID, it really was a storm that came together and made things worse than what we would have hoped it could be. Before we move on out of history, Dr. Jagade, what further would you like to add to this already fruitful discussion? Yes, and thank you to Dr. Mathis and Dr. Antoine. You really set the stage perfectly for this conversation. I think we need to reframe the crisis. What we've said and what is the prevailing thought is this is a wide opioid crisis, but indeed we see that African-Americans have borne the brunt of this crisis. And we should just, not just the opioid crisis, but just the drug crisis in this country. What Dr. Mathis, she really went through the history of systemic racism and criminalization as it relates to African-Americans drugs in this country. But what we see is that there has been the image of the addicted person over many, many years. It's black and brown people. And by that, we have also conceptualized even treatment and interventions as regarding like, we've framed this as a white crisis and the intervention is also looks white. So we need to begin to reframe the conversation to show that indeed African-Americans as individuals and as a community has and continues in fact to face so much of the brunt of this crisis. Going forward. I'm reframing from saying something that I learned in my time in Baltimore, but it may come up later. So next, you're probably wondering what it is, but I'll get to that later. Dr. Antoine, could you shed light on the unique mental health challenges? We'd start talking about substance use disorder, but other additional mental health challenges that African-Americans may face to the opioid epidemic and how a psychiatrist who may be in the audience may be able to provide effective care within that context. Yeah, I think that's a great question. Mental health has a very broad way of looking at it. You could really talk about diagnosis if you wanted to, but I don't think that would do justice to what mental health really is. I think Dr. Tompkins and I went through a system, if you will, that looked at different aspects of what a person experiences, who they are, their biological makeup, even things like their characteristics or trait, similar to how tall a person is and won't go to IQ. That could be a whole other talk in and of itself, but different characteristics. So if you look at what else is going on with mental health, you gotta think about different things in my mind that a person who's black or brown might be going through. I think of things like the Pygmalion effect, which is an old term, but an important term that points to what are the expectations that might influence a person to act? And those go into things psychologically like stereotype threat. What things do people think about when they clutch the purse or where they look away very quickly? And other things like code switching, where we have to maybe adjust the terminology that we use in different contexts. Imposter syndrome is something as well for professionals who may be in the building or people who are in different social contexts. And then even things like ontological fatigue, just being just weary about being in this space that we have to exist in where someone's been shot or someone, again, is on the news for fighting. Worldstar is no longer a thing as much, but seeing these images that cast who we should be, then having to go against that when we're in other spaces, that's also part of daily mental health. And during this growing opioid epidemic that again was heightened by COVID, those are things that also had to be dealt with. And that goes along with the decades and centuries old issues of John Henryism and superwomanism, if you will now, where gender roles really put a lot of pressure onto a person on how they had to operate. And then now we have this opioid epidemic. So the base layer has been centuries old and that pressure has always been there. But now on top of this, people have been misdiagnosed for years. There've been different wrong diagnoses put out there. And even when put in a US UK study, African-Americans have been known to be misdiagnosed with schizophrenia versus something along the lines of depression. So it's a base layer of mistrust, but also psychological issues that plays a big role. No, thank you. And thank you for mentioning that study between the US and the UK and seeing how different before standardization of diagnosis was. And Dr. Mathis, your perspective, because you run a dual diagnosis clinic and your perspective on how easy is it to engage somebody around their mental health condition or diagnosis when they also are African-American and experiencing a lot of other systemic racism? Yeah, great question. So I really do think that, so we could address a lot of aspects of this, right? There's a lot of information and a lot of studies that look at racial concordance between like a provider and a patient in terms of how they're engaging and the kinds of things that they disclose in that encounter. And so you have to think, well, what's happening when there is racial concordance, for example, and then what's happening when there isn't and how can we help to bridge that gap to engage someone in treatment when they present? I think that having a strong foundation and understanding the impact of systemic racism is at the forefront. It is where we start as physicians, as psychiatrists. If we are thinking about engaging folks from Black communities, then we have to have an appreciation for the impact of systems and structures on the experience of being Black in this country. If we don't start there, then we really won't understand the context of our patients' challenges. We won't appreciate some of the nuances of their struggles. We might be thinking only about it from a socioeconomic lens, but there is more to the story than just the socioeconomic disadvantage. There are the experiences of discrimination. There are experiences of discrimination that then impact career opportunities, educational opportunities, all of these things. And so I feel like that's where we have to start. And then we also have to own what we do or don't know. I don't feel that it's our patients' responsibility necessarily to educate us about their culture and who they are and their background, but we shouldn't bring our assumptions to the table. About what this person is experiencing, and we need to own what we do not know about their history. So how do we balance those two things? Have a solid foundation in understanding the impact of systemic racism. And that's when we're thinking about populations and groups of people. And then for the individual in front of you, not making assumptions and owning what you do not know so that you can appreciate their unique experience. And this can look like having cultural humility in your clinical encounter, so that you provide a space where you say, I'm sorry, I'm wondering if this might have a different impact for you, but I'm not sure. Do you feel like this instance when you were at the grocery store and someone was following you around, did you feel that that was discriminatory? Were you experiencing more symptoms of anxiety about going to the stores after that encounter, right? That you maintain a cultural humility and a curiosity while also being very clear about the experience of, at least I should say the systemic and structural factors that contribute to the experience of being a black person in the United States. Oh, and then being humble and admitting what you don't know is not a skill that we practice a lot of psychiatrists. And so thank you for reminding us about that. Dr. Jagade, I was wondering if we could switch a little bit and for you to talk a little bit about the specific factors that contribute to the increased vulnerability. We heard a lot about the numbers in the beginning, but what specific factors increase specifically the African-Americans risk for opioid misuse and addiction? And how can you then target that information to help prevent perhaps an overdose and get people into treatment? Yeah, thank you for the question. It's a very important one, but I wanna say, I wanna approach it and just say that by vulnerability, we're not talking necessarily, actually we're not talking at all about biological vulnerability. We're talking in terms of a structural vulnerability. What is it in our structure that makes African-Americans vulnerable in this situation and in this space that we found ourselves in? First, I think the historical inaccuracies, we need to correct it. Historical inaccuracies in terms of, and I mentioned this a little bit earlier, is this is not just a white crisis. This is a crisis in African-American communities. And it's been a narcotic crisis that African-Americans have been dying for a long time. And by dying, I don't just mean the numbers that we see because the numbers barely scratched the surface. There's still the peripheral, what I call peripheral damages, peripheral numbers that we don't necessarily account for. A structural vulnerability in and of itself is the risk of an individual or group of persons, risk of poor health because, poor health outcomes because of their location as they interface in a society's normative hierarchy. Okay, I'm just thinking about this definition. Three things come to my mind. The first being an individual or group of people. Substance use disorder has been individualized for a long time and still is. Even the treatment interventions is still individualized. Substance use disorders, opioid use disorder is a community. It's the impact is not just the individual. The impact is the community. So that definition puts it in perspective to say, how is it that we have the impact as a community? And then we come to the location of the person, location of the individual, location of the group of people in a society's normative hierarchy, socioeconomic status. How do we perceive power even in this sense? How do we locate ourselves as we interface, as our patients interface in the healthcare system? A healthcare system that is designed to give the results that is given. The healthcare system as it is right now is not a happenstance. It's not something that just happened to be. It's very clearly calculated to get the outcome that we are seeing right now. I.e., African-Americans are dying more. The rate of death is increasing. The opioid overdose necessarily because of the way everything is set up affects African-Americans more. And then I talk about normative hierarchies, white supremacy. What we see right now is not just the exclusion of African-Americans. It is the absolute inclusion of white folk. You know, think about Brooklyn-Northland, for example. You're more likely, three to four times more likely to get Brooklyn-Northland if you're white and middle-class than if you're African-American. Think about methadone. Methadone, you're more likely to get methadone in African-American communities. You're more likely to get methadone from the works of Helena Hanson and the rest of them. You see that methadone is much more available in African-American communities. And methadone is significantly stigmatized. And why is that? Structural racism. Again, it goes to the healthcare system designed the way it is. And what should we do? Well, if we continue to do intervention within the system, we're gonna continue to get the outcomes that we are getting right now. So there has to be a clear understanding that the system as it is must be destructed. We have to make clear understanding that this system as it is, is designed to give the outcomes that it is given, that is producing for us right now. And we have to reimagine the system. We have to destigmatize methadone, expand Brooklyn-Northland access, okay? As it is right now, expand the curriculum, harm reduction, social determinants of health, put everything together to in fact help the structurally vulnerable population. No, and I'm really glad that you brought up Dr. Hanson's work. It's really, really shined a light on that particular thing about medications for opioid use disorder and how certain groups get offered certain ones and certain groups get offered others. And I wonder, I'll throw this out to the, it's going off script a little bit, so I hope that's okay. When you're in your clinical work and where you are in your locations and you're discussing treatment options, how does that discussion go, especially if they come in with their own biases? How do you discuss treatment and helping a person pick the right one that's right for them? I often talk about it in a few ways. One, I always tell them it's not just about the medication because if they say, you know, this is about buprenorphine versus methadone, it's much, much bigger than that. There are a couple of things that go into it. One, what treatment environment do you feel that you can access most easily? Because if you need to go cross town for buprenorphine or go down the street for methadone and you don't have a car, it might actually make a big difference. Number two, it's a question of what fit is it for the things that you need? If you're just talking about the substance use disorder, but ignoring the diabetes and the hypertension, then that might not be the best place for it. So again, it's not just about the medication, but are they looking at the whole picture and does the facility have the ability to do that? Because I think oftentimes what happens is the disparities that we look at is because there is only one part of the person looked at, whether it is the substance use or it is the diabetes or it is the whatever it may be, rather than looking at the whole piece. And that is the definition of underserved. And that's how we get into this space often. So I start out with a simple way of looking at it, simple by saying, hey, I'm gonna be Bob Ross and I'm gonna paint a picture and hopefully that picture is your life. And literally I do that with all my patients now. Everyone gets that, but it's a comfortable way that is culturally understood rather than some type of esoteric, four-year grad school way of looking at it, but a way that's connectable. So that the person feels like they can come back and just get a connectable thing. And then that seems to be the most important thing. Even before I get to the medications, they know what they're gonna get and they understand it. And that makes a big difference, but baking in the transportation and what's the co-pay and all that's very important to know. Otherwise you can give a great medication regimen and a great treatment plan, but they won't be able to follow through. Does it work if it doesn't get in the body? Dr. Mathis. Yes, exactly. Those are wonderful comments, Dr. Antoine. I appreciate your emphasis on a holistic view of the patient and how we are situating the medication in their lives. And that also is communicating a lot of other types of messaging to the patient. It's communicating that they've been heard. It's communicating that other parts of themselves are important to us as physicians. That it actually is really helping with this idea of like the therapeutic alliance because we're agreeing together about sort of what the context of the problem is and how we navigate a solution to that problem together. And I would even argue that that type of approach can help with issues related to mistrust and feeling misunderstood by the medical system because we are not just saying, this is what I think is right for you. We're really hearing and responding to the information that the patient is bringing to us. I would say, in addition to that, in navigating questions and conversations around stigmatizing ideas about medication. When someone is engaging in treatment for the first time, they don't want their family to know, I don't wanna go to that clinic because I don't want so-and-so to see me there. There are all types of things about how medications for opioid use disorder are perceived and within a cultural context. And so that really, that also means we have to listen, and we have to explore, and we have to engage around those questions and concerns. While we want to both remove the stigma, we have to also validate that the patient is engaging in a process that could be stigmatizing. How do we help them navigate the fact that they are engaging in a process that could be stigmatizing? I ask openly, so some people when we have these conversations, they're concerned about X, Y, or Z, or they've heard that methadone decreases your sex drive. We're going to talk about all of our side effects. They've heard that methadone causes you to gain weight. They've heard or they feel like we're just substituting one opioid for another. Are these things that you've heard or felt before? One by one, we're going to talk through whether it's a misconception about the medication, whether it's a side effect about the medication. But I want to have a robust conversation about what they're perceiving and whether or not they're validating where truth is in those perceptions, but also providing them some additional information and context. Then to always also remind folks that medications for opioid use disorder decrease the risk of overdose by 50-80 percent. That this medication is not just to take away the withdrawal symptoms, which it can do, but it's also to help you regain your life. What are the things about your life that you want to be different? This medication can help you to stabilize in a way that allows you to re-engage with your life. Before we move on, and it's just a reminder to myself that we only got 20 minutes left. Can you believe that? We talked a little bit about the individual barriers, but I don't know, Dr. Jegadeh, if you could talk about other barriers that may be societal that would prevent somebody from actually coming in and seeking medication for their opioid use disorder. That's a really great question and is one that I grapple with myself, and when I teach residents and students, we always go through this as what are some of these factors that constitute barriers to our patients coming in, getting treatment? In other words, how is it that we can improve access to care? But before I go into that, I want to say that even when access-related factors are controlled, Black and brown people still have poor outcomes, poor health outcomes. Why is that? Systemic racism. The first thing I tell my colleagues, my students is you need to engage yourself. Think about your own little biases. What are some of those things that could stand in a gap in the way between you and your patients? Do you think, for example, that because someone is homeless or they're experiencing homelessness, that you're not going to prescribe them buprenorphine? Are there other options? What can you do? Do we just throw our hands in the air and say, hey, because they're experiencing homelessness, we can't treat them? We engage ourselves as providers, our own biases, what stand between us and our patient? Then that's individual. At a more societal level, the healthcare system, what do we incentivize? Do we incentivize outcomes or do we incentivize fee-for-service, for example? Those are some of the factors that I think very necessary and important for us to move the needle when we talk now about the opioid crisis. Another thing I think is very, very necessary now is harm reduction. How do we bring into the system a harm reduction perspective? Teach that to our residents, and teach that to our colleagues, and teach that to our healthcare providers. Then social determinants of health. It's not enough by any means to have medications. We know what works. We know what medications are for opioid use disorder. We know what to do. Well, we think what context do we do these things? Do we have a social determinants of health context? How do we treat our patients? These are some of the things I think are necessary to do. I wanted to see from our wonderful hosts, if we have any questions. I think the question I see, I think we just answered. While I wait for other audience questions, and please put it in the chat or the Q&A function. We've talked about individuals, we've talked about barriers in society, but I've always been interested in how the community themselves help each other. Dr. Mathis, if you could talk about some community-driven initiatives that have shown promise in helping to also address this opioid crisis. Yeah, thank you for the question. I will actually piggyback off of Dr. Jagade's last point related to harm reduction services. There are some phenomenal grassroots harm reduction organizations that are like boots on the ground, meeting people in the community where they are, and really helping to not just bridge. Yes, they are bridging an important gap, but it is more than that. There is a humanization and a real sense of just true respect for the individual and that their life and their wellbeing is worth taking that extra step. And not just being in a clinic, not just being in a place where people have to come to them, that they're going to go to community members and meet them where they are, both physically and sort of from a theoretical perspective where they're really just wanting to see how they can be helpful in the moment. And so harm reduction services include, yes, Narcan. It includes needle exchange. It includes safe use kits. So not just needles, but also cookers, pipes, et cetera. It includes wound care in the era of xylosine. These are all components of harm reduction approaches that are happening in grassroots ways. It also includes overdose prevention centers that are happening in some parts of the country. Again, very grassroots and centering black communities and other communities of color, recognizing this disproportionate impact of the opioid crisis on those communities. So there are ways that people are helping one another and communities are finding ways to make attempts at healing themselves while we still try to bridge this gap with other traditional medical services. And if I may, I think when we talk about policies, we need to be very deliberate and intentional about equity, having an equity-based perspective as we develop policies, whether in the hospital level, the healthcare system in general. And when I say equity, equity is different from inequities. Inequalities generally talks about like any difference at all in health outcomes. When those differences are specifically due to avoidable factors, then it becomes inequities. We need to be very less focused on inequity when you wanna make any policy changes. For example, during the COVID pandemic, we wanted people to do telehealth services. It was not enough to say telehealth services for everybody, but we needed to drill in a little bit closer to say, does our patients, can they operate smartphones? Are they gonna benefit from that? Can they afford internet? So it's not enough to say, we're gonna remove every barrier to people prescribing buprenorphine. If everybody's gonna be on the East side of New York, about East side of New York, and they're not going to be in the inner cities where they really need it. So when we develop policies, we need to be sure that those policies have the equity framework. I was in the back of a van, handing out smartphones at the very beginning of the pandemic and teaching my black and African-American patients how to use them, which I didn't go to medical school for, but it was very interesting to get all these resources at my clinic and then having to develop systems to distribute them, and then to make sure people were keeping track of them. Yeah, people don't often think, and I am glad that you put that to us. There is one question. May I just say that I love that you were in the back of a van distributing smartphones during the pandemic. Those are, yes, those are not skills that they taught us in medical school, but that is what has an impact on folks' health. Yeah, and I appreciate the anonymous donor that allowed us for that. We have a couple of questions coming in. And so the first one, I think it's a complicated one, but I'm going to try and distill it down. And it's really thinking from a programmatic perspective and maybe from a data-driven perspective. You have a lot of things that you want to do. You want to overcome socioeconomic barriers. You want to overcome racialized barriers. You have to work within the system of insurance and payment. Do you have, and you want to also just treat not just opioid use disorder, but perhaps all substance use disorders or all mental health conditions. How would you go about determining which one of those is important and developing perhaps a data-driven model to help guide the decisions you make as a clinic director? Go ahead, Dr. Nance. Yeah, you start out now, I'll jump in after you. Okay, so first I would offer just one word of caution when we think about developing models to help us figure out how to prioritize different things in terms of treating individuals. I think that as challenging and as difficult as it is, really maintaining this holistic approach to the person in their care is very important. And often our models, often our modeling systems particularly if we're thinking about how we're inputting data, right? The data that we are inputting is skewed. It is not fully accurate, especially as it relates to minoritized communities, especially as it relates to the African-American community. And so I would just offer a word of caution in terms of thinking about how we utilize models to help us prioritize what aspect of treatment we should or shouldn't focus on. But in terms of clinic models that might help us get to this space of holistic care and that can help us navigate some of the barriers related to payment and the competing issues and challenges that we face. I think that CCBHC, so Certified Community Behavioral Health Centers is a model that is attempting to do more holistic treatment bridging the gap between mental health services and substance use disorder services. So, and this is a federally supported model. So clinics can apply to be a CCBHC and I'm not sure exactly how many states are engaging in this, but it is a federally supported model. And so this model really emphasizes access to treatment. It really emphasizes both integrated mental health and substance use disorder treatment. It requires primary care screening so that individuals are, physical health needs are being addressed, case management services, peer support services. And what is wonderful about this model from a reimbursement standpoint is that it really allows you to expand the breadth of services that you offer. Patients can, for example, come to multiple appointments in one day and you're still being billed for those multiple appointments rather than just saying, oh, you can't see the doctor and therapist on the same day because insurance won't cover it. CCBHC model does away with that. And it allows you to sort of set your reimbursement rate based on the cost of providing the service. So annually, you get to set what your clinic's reimbursement will be based on the cost of providing that really high quality comprehensive care. And so it's something I'm very excited about. And I know a little bit about it because our clinic is a CCBHC. And it's done wonders for our capacity to be able to serve our patients holistically. And in case people missed the actual name of that, do you mind putting it in the chat? Yes, I can. Thank you. Yeah, I think that's a wonderful model. I've talked to a lot of folks at SAMHSA, the federal organization that backs a lot of that. And I think that's a great model. But what I think may be coming down the future, and I'm keeping a amount of time here as I respond, is that, as you pointed out before, Dr. Mathis, the model right now is that they come to us. But I think we need to get to the point where we go to them. And one of my clinics I actually ended up starting or helped start in 2012, we brought a clinic and took it away from our campus and put it in a homeless therapeutic community. And we've had that open since 2012, even during the pandemic, to the point where we've been able to do telehealth during the pandemic and maintain about an 80% engagement rate for substance use disorders with mental health, and also now buprenorphine and starting to get towards methadone. So what I would say is, to the question, where do you prioritize or how do you prioritize? You might wanna think about who's asking for the help. And that might be the homeless communities where people are there. It might be the barbershops and salons where people are there. It might be the churches where people are there. And the interesting part of that though may be, it may not be the priority you think it's gonna be the one that needs to be there. It might be theirs. And it might be a religious aspect to it. It might be, let's just talk about nutrition today. You really do need to meet the community where they are and what they wanna do. So I don't think any of us right now can answer that question appropriately because the community that has the high demand for services, and I say that in a financial way, might actually drive where you start and then you build from there. Almost like with any treatment session, you need to start where they are and then build off of that. It's the same thing for a business model and that's been successful for the clinic that I have directed. And Dr. Jegadee, I'm gonna give you the last question from Dr. Anil Prem. Thank you so much for being here. And Dr. Prem asks, are there racial inequities in the availability and affordability of Narcan? And if so, does this increased risk of overdose deaths in vulnerable communities of color, is that because of it? And do they have a greater exposure to fentanyl? So the, oh, thank you for the question. The question is, do you find that there are racial- Are there any racial inequities in where Narcan is being distributed or perhaps where pharmacies are located? And if so, is that part of the problem with the racial inequities in the overdose deaths of the African-American? Yes, it is. There's emerging literature on this about Narcan distribution, Narcan training, there's inequities in that. In fact, there's a new study at New England General Medicine how that 180 days from an event, an overdose event, African-Americans receive Narcan less, fewer times than, and this was the work of Michael Burnett, I think it is. So there's data on this. And this is one of the reasons, of course, that this overdose is increasing. Another reason is what I find in my work is people who've been using other drugs for years, and you could say they're stable, crack cocaine, cocaine, all this many, many years ago, now are dying, why? Because of fentanyl. There's fentanyl, a mixture of fentanyl now in the drug markets. And these are people who don't necessarily think they are exposed for inadvertent exposures are causing people to die as well in addition to the disparities in Narcan. So to answer the question directly, yes, there's data on this, the racial inequities in Narcan, Narcan distribution, Narcan education. I think we may be at the end of our time. So I may change it back or put it back up to Dr. James to take us out, is that correct? I can go ahead and close out for you all. Thank you all for joining us and for sharing your amazing insight. I'm dropping the survey link here. Please let us know what you all thought, any comments, suggestions. And we will share that as well with our panelists. And please also register for our upcoming webinar, which is on alcohol, risk and resilience, sociocultural risk and resilience in Hispanic community, which will come in February. You can get more information on that at psychiatry.org slash looking beyond. And there will also be a podcast accompanying this webinar. So stay tuned for that. Thank you all and have a great night. Thank you.

Mental Health Equity

Substance use

Addiction

Marginalized communities

Systemic racism

Opioid epidemic

Community-driven initiatives

Cultural humility

Positive change